Wheelchair Seating Demystified

So you buy this new chair. It arrives, and you assemble it, and it sits gleaming in your living room, waiting for you to sit and push. Yet it is missing something fundamental…

…a cushion.

There are about five million different brands, models and types of cushions to choose from, or so it seems when you first venture into the wide world of wheelchair seating.  As much as we would all love to get pressure mapped to figure out which cushion best distributes pressure, most of us cannot afford that luxury, and pressure mapping will only tell you which cushion distributes pressure best, not which is best for your lifestyle. This guide is an intro to wheelchair seating, and will cover cushion type and the positives and negatives of each, as well as my personal recommendations for cushioning surfaces.

Wheelchair cushions can have many purposes. The first and foremost is to reduce the risk of skin breakdown. They do this (generally) by evenly distributing pressure along the buttocks and thighs. Major areas of concern are the ischial tuberosities (IT’s), the bony prominences of the inferior pelvic bones. Most cushions seek to distribute pressure evenly or minimize the pressure over the IT’s – some cushions even reduce pressure over the IT’s completely (with varying degrees of success)

Foam:

Foam cushions are exactly what they sound like, to a point. They range from simple to complex, from basically useless to perfectly balanced. They can be the least expensive type of cushion, though not always. They range in thickness from 2” to about 5” and can be custom molded for those of us with pelvic obliquities and unique positioning needs. Some feature a single layer of foam, while others have between two and five layers of foam of varying weights, viscosities and thicknesses.

Basic single layer low contour foam cushion (Example: Jay Basic)

Positives:

• Cheap
• lightweight
• Stable – makes transfers easy
• Basically maintenance-free
• Better than nothing, offering some (mild) pressure relief

Negatives:

• Retains heat and moisture – this cushion gets very hot in even the most mild weather. If the retention of heat is bad, than the retention of moisture is even worse. This cushion does not breathe at all, which can cause skin breakdown and is downright uncomfortable.
• Client needs to be able to perform pressure reliefs.
• Doesn’t really help with positioning needs aside from the stability
• Easy to bottom out
• Can be cleaned, cannot be sanitized

Multi-layer contour foam cushion (Example: Infinity Gentle Contour)

Positives:

• offers postural support and good pressure distribution for people with close to typical body structures.
• Stable
• helps manage basic positioning needs.
• Basically maintenance free
• Cheap on ebay

Negatives:

• Retains Heat and Moisture
• expensive
• Surprisingly heavy
• Too thick for some applications
• Client needs to perform pressure reliefs
• Can be cleaned, cannot be sanitized

Foam/Gel hybrid cushions:

These cushions have one or more layers of foam and one or more layers of gel. There are many types of foam/gel hybrid cushions. All of them offer more postural support than traditional foam cushions. All of the cushions are heavy, due to the nature of gel being a water-based substance. All gel cushions must be massaged on a weekly basis in order to maintain the fluidity of the gel. Gel cushions are prone to rupture, in which the gel pak gets a hole in it and the gel fluid leaks out. The gel fluid is non-toxic but can stain clothing. Gel cushion paks cannot be repaired once they rupture and must be replaced.

Gel has a limited lifespan which can be shortened by failure to massage the gel paks or temperature extremes. The average lifespan of a gel cushion is 3 years.  The gel pak on the cushion can be a simple overlay spanning the entire surface of the cushion a few millimeters thick, or the cushion can have foam on the front of the cushion and a gel pak in the rear of the cushion up to three inches thick. The purpose of the gel is to immerse bony prominences and thus distribute pressure more equally across the surface.

Basic Gel cushion (example: Relax X-cell)

The Relax X-cell is a single layer, noncontoured foam cushion with a thin gel pak overlay.

Positives:

• Cheap
• Offers more pressure distribution than a standard single layer foam cushion
• Stable

Negatives:

• Retains heat and moisture
• Moderately heavy
• Gel paks can puncture
• Does not help with positioning needs
• Client needs to perform pressure relief

Gel cushion with foam on the front and thick gel pak on the back (Example: Jay Deep Contour)

Positives:

• Aggressive positioning for people with typical body structures
• Thick gel in the back for immersion of the  (IT’s)
• Foam in the front for positioning and stability

Negatives:

• Very heavy
• expensive
• May be too thick for some applications
• Retains heat and moisture
• Gel paks can rupture.

Foam/Air hybrid cushions:

These cushions combine the best of foam and air cushions: the front is made of foam and enhances stability and ease of transfers, and the rear contains air chambers which research has proven are the best way to combat pressure sores. The cushion typically consists of a foam base with air bladders at the rear of the cushion. The air bladders are inflated and then a hand is placed under the IT’s. the air bladders are properly inflated when half an inch to an inch of free space is felt between the fingers and the bottom of the cushion.

Foam/air hybrid (example: roho Nexus)

Positives:

• Air reduces retention of heat/moisture
• Very effective at pressure distribution
• Foam base offers stability and positioning
• Compared to gel/foam, it is lightweight.
• Accounts for mild pelvic obliquities and other mild deformities

Negatives:

• Air bladders are easy to puncture
• expensive
• Foam parts are still hot
• Air pressure must be checked often
• Air part is somewhat unstable as air flows freely between the chambers
• For people with full sensation, air bladders may feel a little odd.

Air Cushions

Air cushions come in several styles. Some are very good at pressure distribution, and some are okay. Many can compensate for moderate deformities and obliquities. All air cushions need to be checked for proper inflation, and all air cushions are at risk of puncture.

Basic air cushion (example: Roho Mosaic)

Positives:

• Cheap
• Somewhat breathable
• Good at pressure distribution
• Compensates for deformities
• Lightweight
• Able to be sanitized

Negatives:

• Unstable
• Can puncture
• Pressure needs to be checked

Single Valve Low/High Profile Air cushion (example: Roho)

Positives:

• good at pressure distribution (low profile moderately good, high profile very good)
• Breathable
• Lightweight
• Able to be sanitized

Negatives:

• Easily punctured
• Expensive
• Unstable

Roho also makes a dual valve cushion. This cushion has two valves so that one half of the cushion can be inflated different than the other half. This is great for people with positioning needs/pelvic obliquities, or who want a more stable cushion.

Quadtro Select Roho Cushions have a selector valve at the front of the cushion which allows either all of the air in the cushion to flow freely among the cells, or divides the cushion into four quadrants. This is great for people with aggressive positioning needs or stability needs.

Funky cushions:

These cushions are made out of funky materials. Generally, each of these types of cushions is made by only one company. They often come in different shapes, sizes and styles.

Supracor Stimulite:

A lightweight, breathable honeycomb cushion. Comes in classic or contoured. Supracor also makes honeycomb sheets, pillows, sandals, and other products

Positives:

• Light
• Breathable
• Durable
• Low maintenance
• Can be washed in the washer
• Stable
• Comfortable

Negatives:

• Must be broken in before they are comfortable, otherwise they feel hard

Ride Designs cushion:

Custom molded for your butt, uses offloading principals to offload the IT’s

Positives:

• Light
• Stable
• Breathable
• Able to modify for pressure sores by scratching some of the cushion surface down

Negatives:

• Hard
• Questionable durability as they have only been on the market a few years
• Feels really funny to sit on, like you are floating on your thighs

BAD CUSHIONS:

These cushions are not acceptable for any application. Yes, I know they make them and therefore they should be useful, but they are not. They are totally inadequate at meeting even the most basic of needs. DON’T USE THEM! They cause more harm than good:

The doughnut:

Positives:

• Cheap

Negatives:

• Uncomfortable
• Useless for pressure management
• Ugly
• Can be punctured
• No positioning help
• They are for old people with hemorrhoids! Even for that application they are useless piles of crap

Cushions with coccyx holes in the back:

Positives:

• Cheap

Negatives:

• Can cause pressure sores around the edge of the cutout
• Made of low grade, low weight foam that does not support the body
• Bottoming out anyway if not positioned perfectly
• Retains heat
• Usually made of cheap foam
• Worthless for pressure management
• Useless, no matter what the application.

Eggcrate cushions

Positives:

• Cheap
• You can make it yourself

Negatives:

• Utterly, totally useless for pressure management
• Made of low grade, low weight foam that does not support the body
• Hot
• Ugly
• Uncomfortable
• Bottoming out
• Retains heat

This is by no means an exhaustive list of all the cushion types out there!

My personal recommendations:

Personally, I adore two styles of cushion, both completely different. They are:

• The Roho Quadtro Select: Works well for me because it is super comfortable and breathable, which are the two most important aspects of a cushion for me. I can’t stand having a sweaty rear, because I have hyperhydrosis (of the hands) and if my butt or anywhere else sweats, it sets off a chain reaction which makes my hands sweat. I can sit on the Roho all day and my butt will not get sore because it conforms to my shape rather than me needing to conform to its shape. I like the stability the quadtro select offers because with the single valve, I feel like there is too much pressure on my thighs around my knees (this is a sensory issue mostly) and so I can use the Quadtro valve to put less air in the front than would normally be there if I had only a single valve. The Roho will not meet everyone’s needs, especially if you are in an environment with high risk of puncture, such as if you weld from your chair, own a cat, or work in a needle factory. Some people with full sensation do not like the feel of the Roho fingers. As my boyfriend says, “this cushion pokes me inappropriately”. The roho may also be too shifty for people, and it may not be stable enough for some people. You are, after all, floating around on a bunch of little air pickles.
• The Supracor Stimulite Classic: I love this cushion because it is fun to feel with your hands – it feels funky! More practically, I like it because it is very breathable, and once broken in, is sort of moulded to your rear. It is also very comfortable, but I found that I can tolerate sitting in it for less time than the Roho, and so the Roho is what I use. I like the stability of the cushion. This cushion is also very durable and will not puncture or break down as quickly as other cushions.

I also think the air/foam combination cushions are intriguing, though I have not tried them for any length of time.

What I have tried, and don’t like: Jay Basic (very, very hot, very uncomfortable), basic flat gel cushions (also very hot and uncomfortable), thick gel cushions (once again too hot, and the contours of the foam did not match my body and therefore was uncomfortable, and various types of contoured cushions. The Roho works best for me because it conforms to my shape, is breathable, and offers the right amount of positioning for me. It is very important to realize that each user is different, and each user has different needs, so there is no cushion that works for everybody.

-Wheelmouse
Your resident OTD/S